Principles of wounds. Primary surgical debridement (PCO) of wounds

31.10.2020

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Primary surgical treatment of a wound in medicine is called a certain surgical intervention, the purpose of which is to remove various foreign bodies, debris, dirt, areas of dead tissue, blood clots and other elements from the wound cavity, which can lead to complications in the treatment process and increase the recovery time and restoration of damaged tissues.

In this article, you will learn the types and algorithms for performing primary surgical treatment of the wound, as well as the principles of PHO, features and types of sutures.

Varieties of primary wound treatment

Conducting primary surgical treatment of wounds, if there are indications for such a procedure, is carried out in any case, regardless of when the victim was admitted to the department. If, for any reason, it was not possible to carry out the treatment immediately after the injury, then the patient is administered antibiotics, most optimally by the intravenous method.

Primary surgical treatment of the wound, depending on the timing of the procedure is divided into:

Of course, the ideal option is the situation when the PHO of the wound is carried out simultaneously immediately after injury and at the same time is an exhaustive treatment, but this is not always possible.

Types and features of seams

Sutures during wound treatment can be applied in various ways, with each type having its own characteristics:

How is the PHO

Primary wound treatment is carried out in several main stages. Algorithm of PHO wound:

The first stage is the dissection of the wound cavity with a linear incision... The length of such an incision should be sufficient for the doctor to carry out all work on the injury. The incision is carried out taking into account the topographic and anatomical features of the structure of the human body, that is, in the direction along the nerve fibers, blood vessels, as well as Langer's skin lines. Layers of skin and tissue, fascia and subcutaneous tissue are dissected in layers so that the doctor can accurately determine the depth of the damage. The muscle is always dissected along the fibers.
The second stage of treatment can be considered the removal of foreign bodies from the wound cavity.... In the case of gunshot wounds, such an object is a bullet, with a shrapnel one - shell fragments, with a knife and cut - a cutting object. In addition, in case of any injury, various small objects and debris can get into it, which must also be removed. Simultaneously with the elimination of all kinds of foreign bodies, doctors also remove dead tissue, formed blood clots, clothing particles, bone fragments, if any. The entire contents of the existing wound canal is also removed, for which the method of washing the wound with a special apparatus with a pulsating stream of solution is usually used.
At the third stage, the tissues that have lost their viability are excised... This removes the entire area of \u200b\u200bprimary necrosis, as well as areas of secondary necrosis, that is, those tissues whose viability is in doubt. Typically, the physician evaluates the tissue according to certain criteria. Viable tissue is characterized by a bright color and bleeding. Living muscles should respond by contraction of fibers when irritated with tweezers.

Secondary surgical treatment

VHO (secondary treatment) is required in cases where a purulent focus and serious inflammation are formed in the wound. At the same time, the protruding ichor does not leave on its own, and purulent streaks and areas of necrosis begin to appear in the wound.

When carrying out secondary treatment from the wound cavity, first of all, accumulations of purulent exudate are removed, and, then, hematomas and blood clots. After that, the surface of the damaged area and the surrounding skin integuments are cleaned.

WMO is carried out in several stages:

Tissues that have no signs of viability are excised.
Blood clots, hematomas and other elements are removed, as well as foreign thallus, if any.
The opening of wound pockets and the resulting leaks is carried out in order to clean them.
Drainage of the secondarily cleaned wounds is carried out.

The difference between primary and secondary treatment is that primary treatment is performed when any wound is received, as well as during operations.

Secondary treatment is carried out only in cases where the primary was not enough and a purulent-inflammatory process began in the wound. In this case, secondary treatment of the wound is necessary to prevent the development of serious complications.

Wounds. Primary surgical treatment. Drainage of wounds.

Wounds. Classification of wounds.

Wound

The main signs of a wound

Bleeding;

Functional impairment.

Elements of any woundare:

The bottom of the wound.

Wounds are classified on various grounds.

Puncture wounds

Cut wounds

Chopped wounds

Scalped wounds patchwork.

Bitten wounds

Poisoned wounds

Gunshot wounds -

- wound channel area

- bruised area

Secondary necrosis zone;

3. By infection

The course of the wound process

During the healing of wounds, the resorption of dead cells, blood, lymph occurs, and due to the inflammatory reaction, the process of cleansing the wound is carried out. The wound walls close to each other are glued together (primary gluing). Along with these processes in the wound, connective tissue cells multiply, which undergo a number of transformations and turn into fibrous connective tissue - a scar. On both sides of the wound, there are opposite processes of neoplasm of blood vessels, which grow into a fibrin clot that sticks together the walls of the wound. Simultaneously with the formation of the scar and blood vessels, the epithelium multiplies, the cells of which grow on both sides of the wound and gradually cover the scar with a thin layer of the epidermis; in the future, the entire layer of the epithelium is completely restored.

Signs of suppuration of wounds correspond to the classic signs of inflammation, as a biological reaction of the body to a foreign agent: dolor (pain);

calor (temperature);

tumor (swelling, edema);

rubor (redness);

functio lesae (dysfunction);

INFLAMMATION

The stage is characterized by the presence of all signs of a purulent wound process. In a purulent wound, there are remnants of non-viable and dead tissue of its own, foreign objects, dirt, accumulation of pus in cavities and folds. Viable tissues are edematous. There is an active absorption of all this and microbial toxins from the wound, which causes the phenomena of general intoxication: an increase in body temperature, weakness, headache, lack of appetite, etc.

Stage treatment objectives: drainage of the wound to remove pus, necrotic tissue and toxins; fighting infection. Wound drainage can be active (using devices for aspiration) and passive (drainage tubes, rubber strips, gauze wipes and turundas moistened with water-salt solutions of antiseptics. Therapeutic (medicinal) agents for treatment:

Hypertonic solutions:

The most commonly used by surgeons is a 10% sodium chloride solution (the so-called hypertonic solution). Besides him, there are other hypertonic solutions: 3-5% boric acid solution, 20% sugar solution, 30% urea solution, etc. Hypertonic solutions are designed to ensure the outflow of wound discharge. However, it was found that their osmotic activity lasts no more than 4-8 hours, after which they are diluted with wound secretion, and the outflow stops. Therefore, recently, surgeons refuse to use a hypertonic solution.

In surgery, various ointments are used on a fatty and petrolatum base; Vishnevsky ointment, synthomycin emulsion, ointments with a / b - tetracycline, neomycin, etc. But such ointments are hydrophobic, that is, they do not absorb moisture. As a result, tampons with these ointments do not provide an outflow of wound secretions, they become only a cork. At the same time, the antibiotics present in the ointments are not released from the ointment compositions and do not have a sufficient antimicrobial effect.

Pathogenetically justified the use of new hydrophilic water-soluble ointments - Levosin, Levomikol, mafenide acetate, oflokain. Such ointments contain antibiotics that easily pass from the composition of the ointments into the wound. The osmotic activity of these ointments exceeds the effect of a hypertonic solution by 10-15 times, and lasts for 20-24 hours, therefore, one dressing per day is enough for an effective effect on the wound.

Enzyme therapy (enzyme therapy):

For the speedy removal of dead tissue, necrolytic drugs are used. Proteolytic enzymes are widely used - trypsin, chymopsin, chymotrypsin, terrilitin. These drugs cause lysis of necrotic tissue and accelerate wound healing. However, these enzymes also have disadvantages: in the wound, enzymes retain their activity for no more than 4-6 hours. Therefore, for effective treatment of purulent wounds, the dressings must be changed 4-5 times a day, which is almost impossible. It is possible to eliminate such a lack of enzymes by including them in ointments. So, Iruksol ointment (Yugoslavia) contains the enzyme pentidase and the antiseptic chloramphenicol. The duration of enzyme action can be increased by immobilizing them in dressings. So, trypsin immobilized on napkins acts for 24-48 hours. Therefore, one dressing per day fully provides a therapeutic effect.

Use of antiseptic solutions.

Solutions of furacillin, hydrogen peroxide, boric acid, etc. are widely used. It has been established that these antiseptics do not have sufficient antibacterial activity against the most frequent causative agents of surgical infection.

Of the new antiseptics, it should be noted: iodopyrone, a preparation containing iodine, is used to treat the hands of surgeons (0.1%) and treat wounds (0.5-1%); dioxidine 0.1-1%, sodium hypochlorite solution.

Physical treatments.

In the first phase of the wound process, quartzing of wounds, ultrasonic cavitation of purulent cavities, UHF, hyperbaric oxygenation are used.

Laser application.

In the phase of inflammation of the wound process, high-energy or surgical laser is used. With a moderately defocused beam of a surgical laser, pus and necrotic tissues are evaporated, thus complete sterility of the wounds can be achieved, which in some cases makes it possible to apply a primary suture to the wound.

GRANULATION

The stage is characterized by complete cleansing of the wound and the execution of the wound cavity with granulations (tissue of bright pink color with a granular structure). It first performs the bottom of the wound, and then fills the entire wound cavity. At this stage, its growth should be stopped.

Stage objectives: anti-inflammatory treatment, protection of granulations from damage, stimulation of regeneration

These tasks are answered by:

a) ointments: methyluracilic, troxevasinic - to stimulate regeneration; fat-based ointments - to protect granulations from damage; water-soluble ointments - anti-inflammatory effect and protection of wounds from secondary infection.

b) herbal preparations - aloe juice, sea buckthorn and rosehip oil, Kalanchoe.

c) the use of a laser - in this phase of the wound process, low-energy (therapeutic) lasers with a stimulating effect are used.

EPITHELIZATION

The stage occurs after the completion of the bottom of the wound and its cavity with granulation tissue. Stage objectives: to speed up the process of epithelialization and scarring of wounds. For this purpose, sea buckthorn and rosehip oil, aerosols, troxevasin-jelly, low-energy laser irradiation are used. At this stage, it is not recommended to use ointments that stimulate the growth of granulations. On the contrary, it is recommended to switch back to water-salt antiseptics. It is helpful to allow the dressing to dry to the wound surface. In the future, it should not be torn off, but only cut along the edges, as it detaches due to epithelialization of the wound. It is recommended to moisten such a dressing from above with iodonate or other antiseptic. In this way, a small wound under the scab is healed with a very good cosmetic effect. In this case, a scar is not formed.

With extensive skin defects, long-term non-healing wounds and ulcers in the 2nd and 3rd phases of the wound process, i.e. after cleansing the wounds from pus and the appearance of granulations, dermoplasty can be performed:

a) artificial leather

b) a split displaced flap

c) walking stem according to Filatov

d) autodermoplasty with a full-thickness flap

e) free autodermoplasty with a thin-layer flap according to Thirsh

At all stages of the treatment of purulent wounds, one should remember about the state of immunity and the need to stimulate it in patients of this category.

The first and main stage in the treatment of wounds in a medical institution is the primary surgical treatment.

Primary surgical treatment of wounds (PCO). The main thing in the treatment of wounds is their primary surgical treatment. Its purpose is to remove non-viable tissue, the microflora in them, and thereby prevent the development of wound infection.

Primary surgical treatment of wounds:

It is usually performed under local anesthesia. Stages:

1. Inspection of the wound, toilet of the skin edges, their treatment with aetiseptic (tincture of iodine 5%, do not get into the wound);

2. Revision of the wound, excision of all nonviable tissues, removal of foreign bodies, small fragments of bones, dissection of the wound, if necessary, to eliminate pockets;

3. The final stop of bleeding;

3. Drainage of the wound, if indicated;

4. Primary wound suture (according to indications);

Distinguish between early primary surgical treatment, carried out on the first day after injury, delayed - during the second day and late - 48 hours after injury. The earlier the primary surgical treatment is performed, the more likely it is to prevent the development of infectious complications in the wound.

During the Great Patriotic War, 30% of wounds were not surgically treated: small superficial wounds, through wounds with small inlet and outlet openings without signs of damage to vital organs, blood vessels, multiple blind wounds.

Primary surgical treatment must be instantaneous and radical, that is, it must be performed in one stage and in the process, non-viable tissues must be completely removed. First of all, they operate on the wounded with an imposed hemostatic tourniquet and extensive shrapnel wounds, with soil contamination of the wounds, in which there is a significant risk of anaerobic infection.

Primary surgical debridement consists in excision of the edges, walls and bottom of it within healthy tissues with the restoration of anatomical relationships.

Initial surgical debridement begins with incision of the wound. With a bordering incision 0.5 - 1 cm wide, the skin and subcutaneous tissue around the wound are excised and the skin incision is extended along the axis of the limb along the neurovascular bundle for a length sufficient to inspect all the blind pockets of the wound and excise non-viable tissues. Further along the skin incision, the fascia and aponeurosis are dissected. This allows a good examination of the wound and reduces muscle compression due to their edema, which is especially important for gunshot wounds.

After cutting the wound, scraps of clothing, blood clots, free-lying foreign bodies are removed and the excision of crushed and contaminated tissues is started.

Muscles are excised within healthy tissues. Muscles that are not viable are dark red, dull, do not bleed when cut and do not contract when touched with forceps.

Intact large vessels, nerves, tendons should be preserved during wound treatment, and contaminated tissues should be carefully removed from their surface. (Small bone fragments freely lying in the wound are removed, sharp, devoid of periosteum, the ends of the bone fragments protruding into the wound are bite off with nippers. If damage to blood vessels, nerves, tendons is found, their integrity is restored. non-viable tissues and foreign bodies are completely removed, the wound is sutured (primary suture).

Late surgical treatment performed according to the same rules as the early one, but with signs of purulent inflammation, it comes down to removing foreign bodies, cleaning the wound from dirt, removing necrotic tissue, opening leaks, pockets, hematomas, abscesses in order to provide good conditions for the outflow of wound discharge.

Tissue excision, as a rule, is not performed due to the danger of generalization of the infection.

The final stage of the primary surgical treatment of wounds is the primary suture, restoring the anatomical continuity of tissues. Its purpose is to prevent secondary wound infection and to create conditions for wound healing by primary intention.

The primary suture is applied to the wound within 24 hours after injury. The primary suture, as a rule, also ends with surgical interventions during aseptic operations. Under certain conditions, purulent wounds are closed with a primary suture after opening subcutaneous abscesses, phlegmons and excision of necrotic tissues, providing in the postoperative period good conditions for drainage and prolonged washing of wounds with solutions of antiseptics and proteolytic enzymes.

The primary delayed suture is applied within 5 - 7 days after the initial surgical treatment of wounds before the appearance of granulations, provided that no wound suppuration has occurred. Delayed sutures can be applied in the form of provisional sutures: the operation ends by stitching the edges of the wound and tightening them a few days later, if the wound has not suppurated.

In wounds sutured with a primary suture, the inflammatory process is poorly expressed and healing occurs by primary intention.

During the Great Patriotic War, the primary surgical treatment of wounds, due to the risk of infection, was not performed in full - without the imposition of a primary suture; used primary delayed provisional seams. When acute inflammation subsided and granulations appeared, a secondary suture was applied. The widespread use of the primary suture in peacetime, even when treating wounds at a later date (12-24 hours), is possible thanks to targeted antibacterial therapy and systematic observation of the patient. At the first signs of infection in the wound, it is necessary to partially or completely remove the stitches. The experience of the Second World War and subsequent local wars showed the inexpediency of using a primary suture for gunshot wounds, not only due to the characteristics of the latter, but also due to the lack of the possibility of systematic observation of the wounded in military field conditions and at the stages of medical evacuation.

The final stage of the primary surgical treatment of wounds, delayed for some time, is the secondary suture. It is applied to a granulating wound in conditions when the danger of wound suppuration has passed. Terms of application of the secondary suture from several days to several months. It is used to accelerate wound healing.

An early secondary suture is applied to granulating wounds within 8 to 15 days. The edges of the wound are usually mobile, they are not excised.

A late secondary suture is applied at a later time (after 2 weeks), when cicatricial changes have occurred in the edges and walls of the wound. The convergence of the edges, walls and bottom of the wound in such cases is impossible, therefore, the edges are mobilized and the scar tissue is excised. In cases where there is a large skin defect, a skin transplant is performed.

Indications for the use of a secondary suture are: normalization of body temperature, blood composition, a satisfactory general condition of the patient, and from the side of the wound, the disappearance of edema and hyperemia of the skin around it, complete cleansing of pus and necrotic tissues, the presence of healthy, bright, juicy granulations.

Various types of sutures are used, but regardless of the type of suture, the basic principles must be observed: there should be no closed cavities, pockets in the wound, the adaptation of the edges and walls of the wound should be maximized. Sutures should be removable, and ligatures should not remain in the sutured wound, not only from non-absorbable material, but also from absorbable material, since the presence of foreign bodies in the future can create conditions for wound suppuration. With early secondary sutures, the granulation tissue must be preserved, which simplifies the surgical technique and preserves the barrier function of the granulation tissue, which prevents the spread of infection to the surrounding tissues.

Healing of wounds sutured with a secondary suture and healed without suppuration is usually called healing by the type of primary tension, in contrast to true primary tension, since, although the wound heals with a linear scar, processes of scar tissue formation occur in it through the maturation of granulations.

Drainage of wounds

Wound drainage plays an important role in creating favorable conditions for the course of the wound process. It is not always carried out, and the surgeon determines the indications for this procedure. According to modern concepts, wound drainage, depending on its type, should provide:

Removal of excess blood (wound contents) from the wound and thereby the prevention of wound infection (any training pitchfork);

Tight contact of the wound surfaces, which helps to stop bleeding from small vessels (vacuum drainage of the spaces located under the flaps);

Active cleaning of the wound (when draining it with constant postoperative irrigation).

There are two main type of drainage: active and passive (Fig. 1).

Types of wound drainage and their characteristics

Figure: left. Types of wound drainage and their characteristics

Passive drainage

It involves the removal of wound contents directly through the line of skin sutures and is able to ensure drainage of only the superficial sections of the wound. This provides for the imposition, above all, of an interrupted skin suture with relatively wide and leaky inter-suture gaps. It is through them that drainages are installed, which can be used as parts of drainage pipes and other available material. By pushing the edges of the wound apart, drainage improves the outflow of wound contents. It is quite understandable that such drainage is most effective when installing drains taking into account the action of gravity.

In general, passive wound drainage is simple, the downside of which is its low efficiency. Drainage with a piece of glove rubber in the photo on the left. Obviously, passive drains are not able to provide drainage of wounds with a complex shape, and therefore can be used primarily for superficial wounds located in those areas where the requirements for the quality of the skin suture can be reduced.

Active drainage

It is the main type of drainage of wounds of complex shape and involves, on the one hand, the sealing of a skin wound, and on the other, the presence of special drainage devices and instruments for carrying out drainage tubes (Fig. 2).

Standard devices for active wound drainage with a set of guides for passing drainage tubes through tissues.

Fig 2. Standard devices for active drainage of wounds with a set of guides for passing drainage tubes through tissues.

An important feature of the active wound drainage method is its high efficiency, as well as the possibility of floor drainage of the wound. In this case, the surgeon can use the most precise skin suture, the quality of which is fully preserved when removing the drainage tubes away from the wound. It is advisable to choose the outlet of the drainage tubes in the "hidden" areas, where additional punctate scars do not worsen the aesthetic characteristics (scalp, axillary cavity, pubic area, etc.).

Active drains are usually removed 1-2 days after the operation, when the volume of daily wound discharge (through a separate tube) does not exceed 30-40 ml.

The greatest drainage effect is obtained from tubing made of a non-wettable material (for example, silicone rubber). The lumen of the PVC tubing can quickly become blocked by clotting. The reliability of such a tube can be increased by its preliminary (before installation in the wound) washing with a solution containing heparin.

Drainage of panaritium: a) drainage tube; b) the introduction of the tube into the wound; c) washing; d) removing the tube.

Failure to drain or its lack of efficiency can lead to the accumulation of a significant amount of wound contents in the wound. The further course of the wound process depends on many factors and can lead to the development of suppuration. However, even without the development of purulent complications, the wound process in the presence of a hematoma changes significantly: all phases of scar formation are lengthened due to a longer process of organizing an intra-wound hematoma. A very unfavorable circumstance is a prolonged (several weeks or even months) increase in the volume of tissues in the hematoma area. The scale of tissue scarring increases, and the quality of the skin scar may deteriorate.

Factors contributing to wound healing:

General condition of the body;

The nutritional status of the body;

Age;

Hormonal background;

Development of wound infection;

Oxygen supply condition;

Dehydration;

Immune status.

Types of wound healing:

Healing primary intention- fusion of the wound edges without visible cicatricial changes;

Healing secondary tension - healing through suppuration;

- healing under the scab -under the formed crust, which should not be removed prematurely, further injuring the wound.

Wound dressing steps:

1. Removing the old bandage;

2. Inspection of the wound and surrounding area;

3. Toilet of the skin surrounding the wound;

4. Toilet of the wound;

5. Manipulation of the wound and preparing it for the imposition of a new bandage;

6. Applying a new bandage;

7. Fixation of the bandage (see section Desmurgy)

Wounds. Classification of wounds.

Wound (vulnus) - mechanical damage to tissues or organs, accompanied by a violation of the integrity of their integuments or mucous membranes. It is the violation of the integrity of the integumentary tissues (skin, mucous membrane) that distinguishes wounds from other types of damage (contusion, rupture, stretching). For example, a rupture of the lung tissue caused by a blunt trauma to the chest is considered a rupture, and in the case of damage with a knife - a lung wound, because there is a violation of the integrity of the skin.

It is necessary to distinguish between the concept of "wound" and "injury". In essence, a wound is the end result of tissue damage. The concept of injury (vulneratio) is understood as the process of damage itself, the entire complex and multifaceted set of pathological changes that inevitably occur during the interaction of tissues and a wounding projectile both in the area of \u200b\u200bdamage and throughout the body. However, in everyday practice, the terms wound and injury are often used interchangeably and are often used synonymously.

The main signs of a wound

The main classic signs of wounds are:

Bleeding;

Violation of tissue integrity;

Functional impairment.

The severity of each sign is determined by the nature of the injury, the volume of damaged tissues, the peculiarities of the innervation and blood supply of the wound canal zone, the possibility of injury to vital organs

Elements of any woundare:

Wound cavity (wound channel);

The bottom of the wound.

A wound cavity (cavum vulnerale) is a space bounded by the walls and bottom of the wound. If the depth of the wound cavity significantly exceeds its transverse dimensions, then it is called a wound channel (canalis vulneralis).

Wounds are classified on various grounds.

1. By the nature of tissue damage:

Puncture wounds applied with a piercing weapon (bayonet, needle, etc.). Their anatomical feature is their considerable depth with little damage to the integument. With these wounds, there is always a risk of damage to vital structures located deep in the tissues, in cavities (vessels, nerves, hollow and parenchymal organs). Appearance and presentation of puncture wounds Does not always provide sufficient data for a diagnosis. So, with a puncture wound of the abdomen, it is possible to injure the intestine or the Liver, but the discharge of intestinal contents or blood from the wound is usually not detected. With a puncture wound, in an area with a large array of muscles, a large artery may be damaged, but external bleeding may also be absent due to muscle contraction and displacement of the wound channel. An interstitial hematoma is formed with the subsequent development of a false aneurysm.

Puncture wounds are dangerous because, due to the small number of symptoms, damage to deep-lying tissues and organs can be seen, therefore, a particularly thorough examination of the patient's wounds is necessary also by the fact that microorganisms are introduced into the depths of the tissues with a wounding weapon, and the wound discharge, not finding a way out , serves as a good breeding ground for them, which creates especially favorable conditions for the development of purulent complications.

Cut wounds applied with a sharp object. They are characterized by a small number of destroyed cells; the surrounding letters are not damaged. The gaping of the wound allows you to inspect the damaged tissue and create good conditions for the outflow of the discharge. With a cut wound, there are the most favorable conditions for healing, therefore, when treating any fresh wounds, they tend to turn them into cut wounds.

Chopped wounds applied with a heavy sharp object (checker, ax, etc.). Such wounds are characterized by deep tissue damage, wide gaping, bruising and concussion of the surrounding tissues, which reduces their resistance and regenerative abilities.

Bruised and lacerated wounds (crushed) are the result of exposure to a blunt object. They are characterized by a large number of crushed, bruised, blood-soaked tissues with impaired vitality. Bruised blood vessels often rhombus. In bruised wounds, favorable conditions are created for the development of infection.

Scalped woundstangent to the surface of the body of the wound inflicted with a sharp cutting object. If the flap remains on the leg, then such a wound is called patchwork.

Bitten wounds are characterized not so much by extensive and deep damage as by severe infection with the virulent flora of the human or animal mouth. The course of these wounds is more often than others complicated by the development of an acute infection. Bite wounds can be infected with the rabies virus.

Poisoned wounds - these are wounds into which poison gets into (when bitten by a snake, scorpion, penetration of toxic substances), etc.

Gunshot wounds - special among the wounds. They differ from all others in the nature of the wounding weapon (bullet, splinter); the complexity of the anatomical characteristics; a feature of tissue damage with areas of complete destruction, necrosis and molecular shock; a high degree of infection; a variety of characteristics (through, blind, tangent, etc.).

I distinguish the following elements of a gunshot wound:

- wound channel area - the area of \u200b\u200bdirect impact of the traumatic projectile;

- bruised area - area of \u200b\u200bprimary traumatic necrosis;

- molecular shock zone- area of \u200b\u200bsecondary necrosis;

A special approach in the treatment of such wounds, and, moreover, very different in peacetime and in wartime, at the stages of medical evacuation.

2. Due to damage to the wound divided into operational (intentional) and accidental.

3. By infectionsecrete wounds aseptic, freshly infected and purulent.

Purulent wound (burn) with areas of necrosis

4. In relation to body cavities (cranial cavity, chest, abdomen, joints, etc.) distinguish between penetrating and non-penetrating wounds. Penetrating wounds pose a great danger due to the possibility of damage or involvement in the inflammatory process of the membranes, cavities and organs located in them.

5. Allocate simple and complicated wounds, in which there is any additional tissue damage (poisoning, burns) or a combination of soft tissue injuries with damage to bone, hollow organs, etc.

The course of the wound process

The development of changes in the wound is determined by the processes occurring in it and the general reaction of the body. In any wound, there are dying tissues, hemorrhage and lymphatic effusion. In addition, a certain amount of microbes gets into wounds, even if they are clean, operating rooms.

All materials on the site have been prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative and inapplicable without consulting your doctor.

Primary surgical debridement of wounds, or PHO, is carried out to ensure early healing by forming an even scar and preventing complications. It is indicated for lacerations, shrapnel, gunshot wounds, infection, hemorrhage, tissue necrosis at the edges of the lesions. The earlier the surgical treatment is carried out, the faster and more favorable the recovery will be.

Wounds are one of the most common types of injuries that a person receives not only in everyday life, but also at work. The problem of wound treatment becomes especially urgent in the context of military operations and armed conflicts, as well as natural disasters. In the latter cases, wounds can be multiple, varying degrees of severity and require serious, painstaking work of surgeons and long-term rehabilitation.

The smoother the edges of the lesion, the higher the chances of favorable healing. However, this is possible only with not too deep, cut wounds, the boundaries of which are well matched. Infection is one of the main factors disrupting the course of the regenerative process and leading to severe purulent-septic complications, which can be avoided by the PCO of the wound.

Almost all types of injuries are subjected to primary surgical treatment, except perhaps for sediments and an insignificant depth of cuts with smooth edges, the distance between which is no more than a centimeter. Such defects can heal on their own, without additional surgical intervention. It is possible to do without PCO in the case of puncture injuries proceeding without complications, as well as through bullet wounds, in which there is no serious injury to soft tissues.

Massive areas of wounds, the presence of foreign objects, deep defects of soft tissues, blood vessels and nerves almost always require the help of a surgeon. However, it will have to be postponed when the injured person is in a state of shock, suffered massive blood loss and requires life-saving surgery and intensive care.

Indications and contraindications for PHO

PCO is needed for any type of injury received no more than three days ago, with crush injury, infection, hemorrhage, tissue diastasis by more than a centimeter, or even without obvious secondary inflammatory changes. The exception is minor sedimentation, scratches, small wounds without injury to deep-lying structures, puncture injuries with intact internal organs, intact neurovascular bundles, sometimes through bullet wounds that are able to regenerate independently.

Only the grave condition of the victim (shocks, coma, agony) and an increase in phlegmonous inflammation in the wound itself can interfere with the conduct of PST. This means that the wound will still be treated, but a little later, after the patient's condition has stabilized.

The main principles during the primary surgical treatment of the wound are necrectomy within healthy tissue, the correct choice of the type of suture, measures to prevent infection, adequate drainage and stop bleeding.

The most effective option is considered when the wound is treated as early as possible, in the conditions of the surgical department and at the same time. For this reason, damage to the tissues of the head, brain, gunshot wounds involving bones are not operated at the primary stages of assistance in military field conditions, except in cases when there is a threat to life due to bleeding, soil contamination, and toxic substances.

The edges of the skin are excised with neat semi-oval incisions that lie within the healthy tissue grafts. It is important to correctly assess the vitality of the tissue based on its appearance. The skin is considered viable if, when it is cut, severe bleeding from the capillaries is found. On the contrary, cyanosis, thinning, severe edema or plethora indicate impending necrosis.

The timing of the PHO and its varieties

The timing of PHO is an extremely important factor affecting the rate of healing and its outcome. The earlier the patient gets to the surgeon, the lower the risk of complications, however, urgent surgical care is not always available in the first hours after injury, so often the injured go to the doctor after a day or even more. At the same time, the forecasts are assessed as rather serious.

At the same time, some potential patients themselves do not rush to the doctor in the hope that everything will heal by itself. After a short time, they observe the addition of infection, suppuration, the appearance of signs of intoxication, and then it is already clear that one cannot do without a specialist.

Depending on the timing in which the PHO was carried out, there are:

Early PHO - carried out within 1 day after injury, includes all the main stages of processing and ends with suturing with the imposition of a primary suture;
Delayed - in the next two days, when inflammatory changes, swelling increase, inflammatory exudation appears, requiring the mandatory appointment of antibacterial agents and opening the wound, a little later, delayed primary stitches are applied;
Late - is carried out after 48 hours or more, when phlegmonous inflammation is present, sutures are not applied, antibiotics and detoxification measures are required.

Primary wound treatment technique and equipment

Primary surgical treatment of a wound is a surgical procedure, which presupposes the presence of appropriate conditions (operating room or dressing room of the surgical department), adherence to the rules of asepsis and antisepsis, and the use of special instruments. Excision of the wound edges, drainage, elimination of abscesses is impossible without adequate anesthesia, which is usually carried out by tissue infiltration with local anesthetics - lidocaine, novocaine and others.

Any surgical department has the instruments necessary for the wound healing process, they are owned by a surgeon of any specialty who can provide emergency surgical aid to a patient in need, even if he independently comes for it, as they say, from the street. All instruments are sterile, and the skin and the incision area are carefully treated with antiseptic agents (iodine, chlorhexidine, hydrogen peroxide, ethanol) to avoid infection.

A set of tools for PCO includes:

Forceps and claws for linen;
Tweezers;
Cutting tools - scalpels and scissors;
Syringes;
Clamps to stop bleeding;
Needles and material for sewing;
Probes and hooks;
Drainage tubes, sterile gloves, bandages, cotton balls and swabs.

In addition to surgical instruments, during the primary surgical treatment of the wound, medications are used - disinfectants (hydrogen peroxide, iodine, ethanol), local anesthetics (lidocaine, novocaine), as well as alcohol and other means for processing instruments.

Primary surgical treatment of wounds consists of a number of sequential stages:

Incisions of the wound edges.
Examination of the wound course, probing the existing cavities, opening them.
Excision of the boundaries of the wound defect, walls and bottom.
Stopping bleeding by coagulation or vascular ligation.
Restoration of the integrity of injured tissues, blood vessels, muscles, etc.
Suturing and, if necessary, drainage.

Thanks to the PST, an accidentally obtained wound with torn, contaminated borders takes on even outlines, gets rid of infection, regenerates faster with scar formation and without suppuration. Naturally, the cosmetic result will also be much better than after complicated festering wounds.

The PCO algorithm for combined wounds involving heterogeneous structures includes sequential stages: elimination of necrotic tissue, stopping bleeding, stitching of nerves, muscles, tendons, resection of nonviable fragments of bone tissue. After these manipulations, stitches are applied, but the wound continues to drain. If an injury occurs on a limb, then it is temporarily immobilized.

At the first stage of the PHO wounds, the surgeon makes even neat incisions with a scalpel, allowing the most complete examination of the nature of the wound channel and its contents, the involvement of surrounding structures, the presence of additional pockets and cavities. The tissues are dissected in layers, the cutting tool moves along the muscle fibers, along the neurovascular trunks.

In a complex wound, foreign objects are found - splinters, chips, splinters, fragments of clothing, as well as clotted blood, dead tissue, bone fragments. They are removed by washing the space with the supply of antiseptic solutions under pressure.

After revision of the wound, it is necessary to excision of the marginal zones, walls and bottom, extraction of dead areas and tissues with symptoms of infection, removal of foreign bodies. The skin is excised sparingly, fat can be removed with scissors wider, up to clearly "live" areas, fasciae are excised where they have lost their relationship with the surrounding structures, and muscles - only in the zone of undoubted nonviability.

When everything superfluous and pathological is removed, the wound can be called cut, and this is an important condition for the correct comparison of its edges, and sterile. To carry out the subsequent stages of primary surgical treatment, the surgeon must change the set of instruments for clean ones, change clothes or treat gloves with antiseptics.

It is recommended to remove the inner borders of the wound in one whole block, retreating a maximum of 2 cm to the periphery. It is important to consider where the wound is located, what is its depth, which tissues were injured and lie in its bottom or walls. The widest removal of the surrounding tissue is indicated for infected, contaminated wounds on the legs, crush and necrosis.

PHO on the face should be as gentle as possible, because the result of the healing will be a cosmetic defect in one way or another. During the initial surgical treatment of facial wounds, the doctor acts as economically as possible, excising only those areas that have undergone necrosis. If the wound is an incision, then its edges are not excised at all.

When internal organs are located in the viable bottom of the wound or its walls, for example, the intestine, heart, lung, brain, then there can be no question of any excision of the wound components. The areas of internal organs and tissue that can be preserved remain in their original place.

The most important stage of PHO is stopping bleeding, which occurs by coagulation of vessels or their ligation. This avoids wound bleeding and secondary infection.

In severe, deep wounds, tendons, muscles, and bone tissue can be injured. If the surgeon has the appropriate skills to restore the integrity of these structures, then it is advisable to do this during the treatment of the wound, however, in conditions of hostilities, it is recommended to postpone restorative operations.

If the surgeon does not possess the technique of reconstruction of nerves, bones, soft tissues, or there are no technical possibilities for these manipulations, the victim will need another operation with the imposition of delayed tendon, muscle sutures, and osteosynthesis.

Wound suturing and drainage are considered the final stage of the PHO, while several options are possible:

crosslinking layer by layer without drainage;
suturing and leaving a drainage tube in the wound;
temporary opening of the wound without sutures and drainages.

A tightly sutured wound can be left with puncture injuries, incisions with a small area of \u200b\u200bsoft tissue injury, without signs of contamination or infection, when the damage is located on visible parts of the body, a short period of time has passed from the moment the wound was received. Under these conditions, the likelihood of complications will be negligible, so there is no need for drainage.

If the surgeon cannot exclude the risk of infection, even when such chances are relatively small, with the location of the wound on the legs, a significant scale and depth of the injury, conducting the PST after 6 or more hours, the presence of a concomitant background that negatively affects the regenerative potential of tissues, suture is shown with the obligatory leaving of drainages.

The most difficult and dangerous wounds cannot be stitched. They are left open due to the high risk of infection, which is facilitated by soil contamination, the presence of crush and bruises, a long time interval between injury and surgery, background anemia, diabetes, immune problems, the victim's advanced age, the location of the wound cavity on the lower extremities. Wounds sustained in wartime or as a result of gunshot injury do not need to be stitched up either.

If the surgeon underestimates the degree of risk, concomitant pathology, the condition of the wound itself and provides a blind suture, then such actions can be considered a serious medical error, because the risk of severe complications cannot be justified by anything.

Early PHO wounds is carried out in accordance with the listed algorithm of actions and ends with a blind seam. For the first two days, drainage can be left in the wound formed from massive damage to the subcutaneous layer, since it is quite difficult to exclude the risk of bleeding. After removing the drainage, the wound is treated as uninfected.

The surgeon can leave an open wound after a delayed PCO, it is necessary to prescribe a wide range of antibiotics. Subsequently, delayed primary sutures are applied. If the doctor is faced with damage that lasts longer than two days, then the risk of purulent inflammation is too great even after surgical treatment and antibiotic therapy, therefore, late PST always leaves an open wound behind. After at least a week, the question of applying a secondary suture can be raised, but for this an important condition is the presence of granulation tissue in the wound.

Drainage is the final stage of PHO. The easiest way to remove discharge from a wound is to install a hollow tube into it, through which blood, pus, and interstitial fluid will passively flow. A more difficult way is the use of double-lumen drainages.

In the conditions of a surgical hospital, the most complex, but also the most effective drainage can be established, the essence of which is the introduction of the washing fluid through one drainage, and the removal of the discharge through the others. It is even better if an aspirator is connected to the outlet drain for active removal of wound contents.

Video: an example of a PHO with a cut thigh wound

The specifics of suturing in PHO and their types

Suturing of tissues and the correct choice of not only technique, but also the timing play an important role in the outcome of the regenerative process and the cosmetic result. Wounds that exist for a long time without sutures are not capable of quick healing. In addition, the presence of an open defect promotes the evaporation of fluid, the loss of protein and important trace elements, as well as the addition of purulent inflammation.

An open wound fills with granulation tissue and epithelializes very slowly, so the surgeon's task is to bring its ends together as early as possible and fasten them with one of the types of suture. Undoubted the advantages of stitching the wound edges are considered:

Shortening the regeneration period;
Reducing the loss of moisture and electrolytes through the wound;
Reducing the risk of secondary suppuration;
Improvement of function in the subsequent and more favorable cosmetic result;
Facilitation of care and treatment of wound elements.

Depending on the timing of the imposition, there are:

Primary seams - actually primary and delayed;
Secondary.

Primary seam It is indicated until granulation tissue begins to develop in the wound, while the damage itself heals by primary intention. This type of suture is possible immediately after the PHO, the end of the surgery. The condition that must be met is the minimum likelihood of suppuration. After scarring and covering the wound with epithelium, the suture is removed. Primary sutures are not recommended for use in case of late treatment of wounds, in war conditions, for gunshot injuries.

Primary delayed sutures they are also applied before granulation tissue appears in the wound, but only when there is a possibility of infection. The surgeon first leaves the wound open, monitors the inflammation, and after its reduction, stitching is possible (in the first 5 days).

A variant of the primary delayed suture is considered provisional: The surgeon sutures the edges of the wound, but does not tie the knots, so the wound remains partially open. You can also tie threads in the next 5 days. This suture holds the edges of the wound, not allowing them to move too far from each other, but at the same time, provides access to the wound surface for examination and control of the course of inflammation.

types of surgical sutures

Secondary seams are shown if the process of formation of granulation tissue has begun in the wound. Healing will occur by secondary intention with the formation of coarse fibrous tissue. Secondary sutures make it possible, if not to eliminate, then at least to reduce the volume of wound cavities.

Open wounds with an abundance of granulations leave behind rough scars, and healing takes quite a long time. With a decrease in the size of the wound cavity, both the volume of granulation tissue and the healing period decrease, and the cosmetic result becomes more beneficial for the patient. In addition, it is more difficult for infectious agents to penetrate through closely spaced edges of the lesion.

Secondary sutures are indicated for wounds with granulations, without suppuration and necrosis. To determine the time when you can start suturing, it is advisable to sow the discharge: if there are no pathogenic microbes, then it's time to apply secondary sutures.

The secondary suture can be early and late. Early applied in the next three weeks from the moment of damage, late - after 21 days or more. The main difference between these types of stitches is in the condition of the wound. Up to three weeks, there is still no obvious scarring in it, so the edges come together, and the threads are tied. When using a late suture, the surgeon has to remove cicatricial changes, only after that it is possible to stitch the wound. For purulent wounds, an additional approach of the edges with a plaster is applied.

In parallel with the surgical treatment of wound defects, patients with complex injuries are prescribed antibacterial, detoxification therapy, adequate anesthesia is mandatory, and corticosteroids are used to combat the inflammatory process.

Thus, PHO is a complex surgical manipulation that may require the surgeon to possess special skills in the imposition of complex sutures (on nerves, tendons, etc.), the availability of specialized instrumentation, operating room conditions, so it is not always possible outside of specialized surgical clinics. ... Its success depends not only on the qualifications of the doctor and the equipment of the hospital, but also on the time that has passed since the injury and its features.

Video: carrying out PHO

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Primary surgical debridement — surgical intervention aimed at removing non-viable tissues, preventing complications and creating favorable conditions for wound healing.

The prevention of the development of complications is achieved by a sufficiently wide dissection of the inlet and outlet, removal of the contents of the wound canal and obviously non-viable tissues that make up the zone of primary necrosis, as well as tissues with questionable viability from the zone of secondary necrosis, good hemostasis, and complete drainage of the wound. The creation of favorable conditions for wound healing is reduced to the creation of conditions for the regression of pathological phenomena in the zone of secondary necrosis by influencing the general and local links of the wound process.

Primary surgical debridement, if indicated, is performed in all cases, regardless of the time of admission of the wounded. In military field conditions, the primary surgical treatment of a wound may be forced to be postponed if there are no urgent and urgent indications. In such situations, to prevent the development of purulent-infectious complications, paravulnar and parenteral (preferably intravenous) antibiotics are used.

Depending on the timing, the primary surgical treatment is called earlyif performed on the first day after injury; delayedif performed during the second day; lateif performed on the third day or later.

The initial surgical debridement of the wound should ideally be comprehensive and immediate... This principle can be optimally implemented in the provision of early specialized surgical care. Therefore, at the stages of evacuation, where qualified surgical care is provided, primary surgical treatment of wounds of the skull and brain is not performed, and primary surgical treatment of gunshot fractures of bones is performed only in cases of damage to the main vessels, infection of wounds with OS, RV, soil contamination and extensive damage to soft fabrics.

Primary surgical treatment of a gunshot wound as a surgical intervention includes six stages.

The first stage is cutting the wound (Fig. 1) - is made with a scalpel through the inlet (outlet) opening of the wound channel in the form of a linear incision of sufficient length for subsequent work on the damaged area. The direction of the incision corresponds to the topographic and anatomical principles (along the vessels, nerves, Langer's skin lines, etc.). The skin, subcutaneous tissue and fascia are dissected layer-by-layer. The fascia is dissected on the extremities (Fig. 2) and outside the operating wound along the entire segment in the proximal and the rest of the Z-shaped directions for decompression of the fascial cases (wide fasciotomy). Focusing on the direction of the wound channel, muscles are dissected along the course of their fibers. In cases where the extent of muscle damage exceeds the length of the skin incision, the latter expands to the boundaries of the damaged muscle tissue.

Figure: 1. The technique of primary surgical treatment of a gunshot wound: wound dissection

Figure: 2. The technique of primary surgical treatment of a gunshot wound: wide fasciotomy

The second stage is the removal of foreign bodies: wounding shells or their elements, secondary fragments, scraps of clothing, free-lying bone fragments, as well as blood clots, pieces of dead tissue that make up the contents of the wound canal. To do this, effectively washing the wound with antiseptic solutions with a pulsating stream. Individual foreign bodies are located deep in the tissues and to remove them, special approaches and methods are required, the use of which is possible only at the stage of providing specialized care.

The third stage is excision of nonviable tissues(Fig. 3), that is, excision of the zone of primary necrosis and the formed areas of secondary necrosis (where the tissues have questionable viability). The criteria for the preserved vitality of tissues are: bright color, good bleeding, for muscles - contractility in response to irritation with tweezers.

Figure: 3. The technique of primary surgical treatment of a gunshot wound: excision of non-viable tissue

Excision of non-viable tissues is carried out in layers, taking into account the different reactions of tissues to damage. The skin is the most resistant to damage, therefore it is excised with a scalpel sparingly. Avoid cutting out large round holes ("dimes") around the entrance (exit) hole of the wound channel. The subcutaneous tissue is less resistant to damage and therefore is excised with scissors until there are clear signs of vitality. The fascia is poorly supplied with blood, but it is resistant to damage, so only those parts of it that have lost contact with the underlying tissues are excised. Muscles are the tissue where the wound process is fully developed and in which secondary necrosis progresses or regresses. Scissors are methodically removed explicitly non-viable mice: brown, do not shrink, do not bleed when surface layers are removed... Upon reaching the zone of viable muscles, hemostasis is carried out in parallel with the excision.

It should be remembered that the zone of viable mice is mosaic in nature. Muscle areas where viable tissues clearly predominate, although minor hemorrhages occur, foci of reduced vitality are not removed. These tissues constitute the zone of "molecular shock" and the formation of secondary necrosis. It is on the nature of the operation and subsequent treatment that the course of the wound process in this zone depends: the progression or regression of secondary necrosis.

The fourth stage is surgery on damaged organs and tissues: skull and brain, spine and spinal cord, on the organs of the chest and abdomen, on the bones and organs of the pelvis, on the main vessels, bones, peripheral nerves, tendons, etc.

Fifth epap - wound drainage (Fig. 4) - creating optimal conditions for the outflow of wound discharge. Drainage of the wound is carried out by installing tubes into the wound formed after surgical treatment and removing them through counter-openings in the places that are lowest in relation to the damaged area. With a complex wound channel, each pocket must be drained with a separate tube.

Figure: 4. Technique of primary surgical treatment of a gunshot wound: wound drainage

There are three options for draining a gunshot wound. The simplest is passive drainage through a thick single lumen tube (s). More complex - passive drainage through a double-lumen tube: through a small channel, continuous drip irrigation of the tube is carried out, which ensures its constant functioning. Both of these methods are used in the treatment of non-extinguished wounds and are the method of choice during the stages of providing qualified surgical care.

The third method is supply and flow drainage- used for a tightly sutured wound, that is, at the stage of providing specialized surgical care. The essence of the method consists in installing an inlet PVC tube of a smaller diameter (5-6 mm) and an outlet (one or more) silicone or PVC tube of a larger diameter (10 mm) into the wound. In the wound, the tubes are installed in such a way that the liquid washes the wound cavity through the inlet tube, and flows freely through the outlet tube. The best effect is achieved with active tidal drainage, when the outlet tube is connected to the aspirator and a weak negative pressure of 30-50 cm of water column is recognized in it.

The sixth stage is wound closure. Taking into account the characteristics of the gunshot wound (presence of a zone of secondary necrosis) the primary suture after the initial surgical treatment of the gunshot wound is not applied.

The exception is superficial wounds of the scalp, wounds of the scrotum, and the penis. Breast wounds with open pneumothorax are subject to suturing, when the defect of the chest wall is small, there are few damaged tissues and there are conditions for closure of the defect without tension after full primary surgical debridement of the wound; otherwise, ointment dressings should be preferred. During laparotomy, from the side of the abdominal cavity after processing the edges, the peritoneum is tightly sutured in the area of \u200b\u200bthe inlet and outlet of the wound canal, and the wounds of the inlet and outlet themselves are not sutured. The primary suture is also applied to surgical wounds located outside the wound canal and formed after additional access to the wound canal - laparotomy, thoracotomy, cystostomy of access to the main vessels along the length, to large foreign bodies, etc.

After the initial surgical treatment, one or more large gaping wounds form, which must be filled with materials that have a drainage function in addition to the installed drain pipes. The simplest way is to introduce gauze napkins moistened with antiseptic solutions or water-soluble ointments in the form of "wicks" into the wound. A more effective method is filling the wound with carbon sorbents, which accelerate the process of wound cleaning (used at the stage of providing specialized medical care). Since any dressing in the wound loses its hygroscopicity and dries up after 6-8 hours, and dressings at such intervals are impossible, graduates must be installed in the wound along with napkins - polyvinyl chloride or silicone "half-tubes", that is, tubes with a diameter of 10-12 mm cut lengthwise into two halves.

In the absence of infectious complications after 2 ~ 3 days, the wound is sutured delayed primary suture.

After primary surgical treatment, as after any surgical intervention, a protective and adaptive inflammatory reaction develops in the wound, manifested by plethora, edema, and exudation. However, since tissues with reduced viability can be left in the gunshot wound, inflammatory edema, disrupting blood circulation in the altered tissues, contributes to the progression of secondary necrosis. In such conditions the effect on the wound process is to suppress the inflammatory response.

For this purpose, immediately after the initial surgical treatment of the wound and during the first dressing, an anti-inflammatory blockade is performed (according to I. I. Deryabin - A. S. Rozhkov) by introducing a solution of the following composition into the wound circumference (the ingredients are calculated per 100 ml of novocaine solution, and the total volume of the solution is determined by the size and nature of the wound) 0.25% novocaine solution 100 ml glucocorticoids (90 mg prednisolone), protease inhibitors (130,000 IU kontrikala) broad-spectrum antibiotic - aminoglycoside, cephalosporin, or their combination in a double single dose. Indications for repeated blockades are determined by the severity of the inflammatory process.

Repeated surgical debridement of the wound (for primary indications) performed when identifying on the dressing to progress secondary necrosis in the wound (in the absence of signs of wound infection). The purpose of the operation is to remove the necrosis of the diatostika and eliminate the cause of its development. If the main blood flow is disturbed, large muscle masses, muscle groups are necrotic - in cases of necractomy, they are extensive, but measures are taken to restore or improve the main blood flow. The reason for the development of secondary necrosis is often errors in the technique of the previous intervention (inadequate dissection and excision of the wound, failure to perform fasciotomy, poor hemostasis and drainage of the wound, the imposition of a primary suture, etc.).

E.K. Humanenko

Military field surgery